In selected patients with anterior-circulation large-vessel stroke 24-72 hours after onset, thrombectomy improved 90-day function but increased hemorrhage and death

1. Results from a large, open-label, multi-site study in China suggest there is benefit for long-term functional outcome, lower rates of disability for mechanical thrombectomy in patients 24 to 72 hours after symptom onset or last known well following an acute ischemic stroke. Standard of care to this point has emphasized the utility of mechanical thrombectomy only within 24 hours of symptom onset or last well known.

2. Patients who were randomized to the mechanical thrombectomy group were found to have a better functional outcomes compared to the control group as well as lower rates of disability in those who survived. However, there were higher percentages of death, intracranial hemorrhage, and overall serious adverse events in the intervention group compared to the control group.

Evidence Rating Level: 1 (Excellent)

Study Rundown: An open-label, multi-site, randomized trial conducted at stroke centers across China compared endovascular therapy in combination with standard medical care (intervention group) versus medical care alone (control group) in patients 24 to 72 hours after symptom onset or last known well following an acute ischemic stroke that was confirmed on computed tomographic (CT) or magnetic resonance angiography. A total of 336 patients were ultimately included in the intention-to-treat population. The median time from symptom onset or from the point when the patient was last known to be well was 38.5 hours, and the median time from randomization to arterial puncture in the intervention group was 1 hour. Successful reperfusion was achieved in 94.6% of the intervention group for which data was available. The  primary outcome was the distribution of modified Rankin Scale scores at 90 days. Of note, more patients in the intervention group than the control group were admitted to the intensive care, received glucocorticoids, were intubated and mechanically ventilated, and received nasogastric feeding. At 90-day follow-up, the intervention group was found to have a statistically significant better functional outcome as measured by the modified Rankin scale. The treatment benefit was most pronounced in those with occlusion of the internal carotid artery as well as those with non-large-artery atherosclerosis. In addition, the rate of disability among surviving patients was lower in the intervention group compared to the control group. However, there was a higher rate of death in the intervention group compared to the control group, as well as higher rates of intracranial hemorrhage and overall serious adverse events.

Click here to read the study in the NEJM (New England Journal of Medicine)

Relevant Reading: Clinical Outcomes and Identification of Patients With Persistent Penumbral Profiles Beyond 24 Hours From Last Known Well | Stroke

In-Depth [randomized controlled trial]: This was an open-label, prospective, randomized trial with blinded outcome assessment conducted at 35 comprehensive stroke centers across China that included adult patients with acute ischemic stroke caused by large-vessel occlusion of the anterior circulation confirmed by imaging (either CT or MRI). Patients were eligible if they were within 24 to 72 hours after symptom onset or last known well following an acute ischemic stroke. They must have exhibited evidence of a neurologic deficit as indicated by a validated scoring system (National Institutes of Health Stroke Scale) and had evidence of salvageable brain tissue on imaging. Patients were randomized to either receive endovascular therapy in addition to standard medical care or standard medical care alone. The patients assigned to the intervention group underwent endovascular therapy within 60 minutes after randomization, and the choice of thrombectomy device, approach, and other adjunctive techniques as determined by the treating physician. Both groups received the standardized Chinese guideline-recommended medical care. The mean duration of hospitalization was 2.4 days longer (95% CI, 0.6 to 4.2) in the intervention group than in the control group. The modified Rankin scale at 90 days, used to assess functional outcome, favored endovascular therapy over standard medical care alone (common odds ratio for a better functional outcome, 1.74; 95% confidence interval [CI], 1.19 to 2.55; P=0.005). Disability among surviving patients was less common in the intervention group than in the control group (48.4% vs. 64.0%; odds ratio, 0.53 [95% CI, 0.34 to 0.82]). However, death within 90 days occurred in 10 of 167 patients (6.0%) in the intervention group, and in 3 of 167 patients (1.8%) in the control group (odds ratio, 3.48; 95% CI, 0.94 to 12.89). An intracranial hemorrhage occurred in 47 of 166 patients (28.3%) in the intervention group and in 9 of 164 patients (5.5%) in the control group (odds ratio, 6.82; 95% CI, 3.21 to 14.47). More patients in the intervention group than in the control group had a serious adverse event (22.0% vs. 13.1%).

Citation: Yang P, Shen H, Yi T, Xing P, Su J, Wen C, et al. Mechanical Thrombectomy 24 to 72 Hours after Large-Vessel Ischemic Stroke. N Engl J Med. 2026 Oct 23. doi: 10.1056/nejmoa2609362. Epub ahead of print. PMID: 42929656.

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